GI: Anorectal disorders Flashcards
What is pruritis ani?
Itch that occurs around the anus
What can cause pruritis ani?
- Moist/solied anus
- Fissures
- Incontinence
- Poor hygeine
- Tight pants
- Threadworm
- Fistula
- Dermatoses
- Lichen sclerosis
- Anxiety
- Contact dermatitis
How would you treat someone with pruritis ani?
- Avoid scratching
- Improve perianal hygeine
- Avoid foods which loosen stool
- Soothing ointment
- Topical steroids (max 2 weeks)
- Oral antihistamine
What are anal fissures?
Painful tears in the squamous lining of the lower anal canal. Often, if chronic, they will have a sentinal pile or mucosal tag at the external aspect
What sex do anal fissures occur more commonly in?
Males
What are causes/predisposing features of anal fissures?
- Hard stools - most common
- IBD esp crohns
- Constipation
- Syphillis
- Herpes
- Trauma
- Anal cancer
- Psoriasis
Rsk factors of anal fissure
Constipation
Dehydration
Inflammatory bowel disease
Chronic diarrhoea
Prsesentation of anal fissure
90% in posterior midline (anterior more common following birth)
- PAINFUL bleeding post defication
- “like passing broken glass
Why do anal fissures take a significant amount of time to heal?
Spasm around the area leads to relative ischaemia, meaning that fissures take longer to heal
What might you consider doing in someone with anal fissures if you suspected a sinister cause?
Proctoscopy/Sigmoidoscopy
How would you manage someone with anal fissures?
- Dietary fibre
- Fluids
- Stool softener
- Hygeine advice
-
Consider medical
- Topical 5% lidocaine + 0.2% GTN Paste (
- Topical 2% Diltiazem
What medical treatment can be used to treat anal fissures?
- Topical 5% lidocaine + 0.2% GTN Paste
- GTN ointment relaxes internal sphincter by increasing blood supply
- Topical 2% Diltiazem
- A CCB relaxes internal sphincter by preventing spasm
- Botulinium toxin
- Relaxes internal sphincter, lasts for 2 months.
What would you consider dioing in a patient with anal fissures where conservative and medical management has failed?
Sirgical management
Lateral partial internal sphinterectomy
Indicated if conservtive measures fail or chronic fissure - incontinence
What is a anorectal abscess?
Abscess which is usually caused by gut bacteria, which can occur in the perianal, ischiorectal, intersphincteric or supralevator regions
Predisposing factors to ano-rectal abscess
CD
DM
Malignancy
Immunosupression
What is thought to cause ano-rectal abscess
Thought to b plugging of anal ducts (which drain anal glands). Blockage of these ducts cause stasis of bacteria
Presentation anorectal abscess
Pain +/- localised severe itching/discharge
Wrose on sitting down
Systemic features in severe eg feature
Typical bacteria anorectal abscess
E. Coli
Enterococcus
Bacteriods
How would you manage a perianal abscess?
Incise and drain under GA
Antibiotics
What diseases are perianal abscesses associated with?
- Diabetes mellitus
- Crohn’s
- Malignancy
- Fistulae
What is a fistula in ano?
A track communicating between the skin and anal canal/rectum. Often occurs following the development of an abscess
How do fistulae in ano form?
Blockage of deep intramuscular gland ducts thought to predispose to the formation of abscesses, which discharge to form fistulas
What are causes of fistula-in-ano?
- Perianal disease (majority)
- Abscesses
- Crohn’s Disease
- TB
- Diverticular disease
- Rectal carcinoma
- Immunocompromise
What is goodall’s rule?
Predicts trajectory of fistula depending on location
If anterior it tracts in a straight line
If posterior the internal opening is at the 6 oclock position ( curved)
Presentation of anal fistula
Pain - throbbing and constant
Perianal dishcarge (blood and pus) - as a result of associated infection
What is the following type of fistula-in-ano?
Transphincteric fistula